The proposed project will address important public health questions, highly relevant to the mission of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), about withdrawal of dialysis in patients with end-stage renal disease (ESRD). Worldwide, there are nearly two million dialysis-requiring ESRD patients. In the United States and Europe, approximately 10% voluntarily elect to withdraw, but relatively little is known about this phenomenon. The aims of this project are to (1) determine the burden of comorbid events, degree of healthcare utilization, and magnitude of poor functional status/frailty in the period preceding dialysis withdrawal, in order to characterize the clinical experience of dialysis withdrawal, and (2) model the comorbidity-, healthcare utilization-, and frailty/functional status- related factors associated with death from ESRD due to dialysis withdrawal, as compared with these factors in dialysis patients who (a) die from other causes and (b) continue to survive on dialysis. The work will be accomplished by creating and analyzing a large, retrospective cohort of Medicare-eligible dialysis patients (approximately 64,000 in number) via use of a large administrative dataset obtained from the United States Renal Data System. By creating a far more complete and granular picture of the dialysis-withdrawal experience, this project will not only yield important public health data, but will also inform discussions between patients and providers about how the end of life unfolds in dialysis patients. This small research grant will also yield data for more ambitious dialysis withdrawal-related research projects, for which NIDDK funding will be sought in the future.